Group Med Privacy Consent Group medical visits are medical appointments conducted in a group setting in which the physician and each patient discuss the patient’s personal medical condition and treatment in the presence of the group. Because each patient will be disclosing personal health and other personal information to the group, participation in group medical visits and the release of personal health information within the group is strictly voluntary and is not required in order to receive treatment from Alabama Lifestyle Medicine.Consent, Authorization to Disclose and Confidentiality AgreementBy signing this agreement, I consent to participate in group medical visits at Alabama Lifestyle Medicine. I authorize Alabama Lifestyle Medicine physicians/allied health professionals conducting the group medical visit in which I participate to disclose my personal health and other private information (“Private Information”) in the presence of all participants attending the group medical visit. I also agree to respect the privacy of all participants, including their family members, who attend the group medical visit by keeping their Private Information confidential and not disclosing such information. I acknowledge the possibility that my Private Information may be disclosed by other participants in the group medical visits contrary to their Confidentiality Agreement, and I voluntarily assume all of the risks associated with such disclosure. I understand that I may revoke this authorization at any time by delivery of a dated and signed request sent to Alabama Lifestyle Medicine, 2208 University Blvd., Birmingham AL 35233 or firstname.lastname@example.org. I understand that such revocation will not prevent Alabama Lifestyle Medicine from making any disclosures already made or taking any actions already taken in reliance on this authorization prior to the receipt of such revocation. Further, I understand that such revocation will preclude my participation in additional Alabama Lifestyle Medicine group medical visits, but will not prevent me from receiving other types of treatment from Alabama Lifestyle Medicine. If not previously revoked, this authorization will expire at the conclusion of my treatment through Alabama Lifestyle Medicine group medical visits.THE INFORMATION AUTHORIZED FOR RELEASE MAY INCLUDE INFORMATION INDICATING THE PRESENCE OF CONDITIONS INCLUDING, BUT NOT LIMITED TO, DIABETES, HIGH BLOOD PRESSURE, HIGH CHOLESTEROL, HEART DISEASE, DEPRESSION, ANXIETY, CONSTIPATION, GASTROESOPHAGEAL REFLUX DISEASE, OTHER GI CONDITIONS, KIDNEY DISEASE, OBSTRUCTIVE SLEEP APNEA, GOUT, CANCER AND ARTHRITIS.ParticipantFill out form.Patient Signature(Required)Reset signature Signature locked. Reset to sign again Name(Required) First Last Date(Required) MM slash DD slash YYYY Staff WitnessFill out form.Staff SignatureReset signature Signature locked. Reset to sign again Name First Last Date MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.